Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacific Care Center during CMS and state inspections, most recent first.
Failure to document wound staging and medication administration: A resident with a coccyx wound had repeated wound assessments that did not include a stage until the wound was later documented as unstageable, despite orders for wound care and staff acknowledgment that nursing and the DON were responsible for staging. Another resident ordered Vancomycin for C. diff had multiple missed or undocumented doses on the MAR, and staff did not notify the nurse or provider when the antibiotic was not administered.
Failure to maintain required RN coverage: Facility records showed repeated weekends with no RN in the building for eight consecutive hours, including multiple gaps across several months. The HR director acknowledged the staffing issue and stated the facility had not realized that split 12-hour shifts would not meet the RN coverage requirement. The DON and administrator both confirmed ongoing RN staffing problems, especially on weekends, with two PRN RNs available.
Medication administration errors exceeded the allowed threshold, with 3 errors in 35 observed opportunities for an 8.57% error rate. One resident's Cephalexin was not given at the ordered time because the CMT said it was unavailable, while another resident's Midodrine and Pantoprazole were administered outside the ordered time window. The DON stated that failing to follow the seven rights of medication administration and giving meds outside the ordered time are medication errors.
Improper medication storage was found in three of five sampled med carts when staff failed to keep drugs and biologicals in their original containers and properly labeled. The D hall cart contained multiple unidentified loose pills and capsules, opened and undated liquid protein, and opened food items with pills; the C hall and A hall carts also contained numerous unidentified loose pills and capsules. The DON, a CMT, and the Administrator each described inconsistent cart maintenance and cleaning expectations, and the Administrator stated the loose pills could lead to med errors.
The facility failed to maintain its IPCP, including missing written and annually reviewed policies and incomplete infection surveillance and antibiotic tracking records. Staff also failed to post EBP signage for a resident with wounds, failed to wear gown and gloves for another resident on EBP, and did not follow TBP for a resident with C-diff when entering the room, providing care, and handling equipment. During medication pass, a CMT and the DON did not perform hand hygiene between residents or after resident contact, despite policies requiring handwashing or antiseptic use before medication administration and between resident contacts.
Failure to Maintain Antibiotic Stewardship Monitoring and Tracking: The facility did not implement its ASP as written, and the IP/DON did not maintain a process to track and trend antibiotic use. Infection/antibiotic control logs were missing for multiple months, and the logs that were completed showed repeated gaps in documentation for signs and symptoms, infection site, onset, culture status, pathogen identification, and infection resolution. The DON stated the logs were not being filled out consistently and that no trending was being done, while the administrator was unaware the monitoring was not occurring.
Staff failed to maintain a comfortable sound level when a broken keypad on a secure exit door caused a loud beeping noise every time the door was used over an extended period. The door, which led to the laundry area and was used frequently by CNAs, laundry, housekeeping, and maintenance staff, emitted a loud alarm-like sound for at least 15 seconds with each use. A resident reported being awakened early in the morning and feeling distressed by the constant beeping, while another resident said the noise sounded like a fire alarm and occurred throughout the day and sometimes at night, bothering everyone. Staff acknowledged the keypad had been broken for weeks, but facility leadership, including the DON and administrator, were unaware of the issue until surveyors arrived, and the maintenance director reported delaying repair pending payment of invoices.
Failure to post accessible State complaint hotline information. The facility did not post the required DHSS hotline information or a list of SA names, addresses, and phone numbers in a form and manner accessible to residents and visitors. Staff posted the Elder Abuse Hotline information in a location that residents, CNAs, and an LPN were not aware of, and a resident said he/she had to find it. The DON and administrator acknowledged the sign may have been too high, too small, and not clearly visible.
Dialysis Care Orders and Clinic Contract Missing: A resident with ESRD who received dialysis had no documented contract between the facility and the dialysis clinic, and the chart lacked physician orders for dialysis and AV graft checks. The resident said staff only sometimes checked the AV graft, while an LPN and the DON confirmed the orders were missing and the facility did not have a copy of the clinic contract.
The facility failed to notify the State LTC Ombudsman of resident transfers to the hospital for four residents. The facility lacked a policy for such notifications, and staff interviews revealed confusion and lack of communication regarding the notification process. The SSD relied on bed hold information from nursing staff, which was not consistently provided, leading to incomplete notifications.
The facility failed to notify residents and their representatives in writing about the bed hold policy during transfers to hospitals or therapeutic leave. This issue affected four residents, with no documentation found in their medical records. Interviews with staff revealed confusion and lack of accountability regarding the completion and monitoring of bed hold forms, contributing to the deficiency.
The facility failed to develop and implement comprehensive care plans for several residents, leading to discrepancies between care plans and physician orders. Issues included inaccurate documentation of hospice services, missing directions for medications and dietary needs, conflicting code status information, and unaddressed use of bed rails and smoking habits. Staff interviews revealed that care plans were not updated as required, contributing to these deficiencies.
The facility failed to provide scheduled showers for eight residents due to an inaccurate master shower schedule. Residents, including those with cognitive impairments and hospice care, were not consistently listed, leading to missed showers. Staff interviews revealed confusion over responsibility for updating the schedule, resulting in inadequate care.
The facility failed to conduct necessary bed rail assessments and obtain informed consent for three residents, despite having a policy requiring these actions. Observations showed consistent use of bed rails without updated assessments or consents. Interviews revealed confusion among staff about responsibilities for bed rail assessments and consent, contributing to the deficiency.
The facility failed to ensure that four nurse aides completed the required training within four months of employment. Personnel files lacked documentation of completed training, and one aide did not perform proper hand hygiene during care. Interviews revealed a lack of clarity and communication regarding responsibility for monitoring training completion, resulting in non-compliance and continued work without completed training.
The facility failed to follow its policy for narcotic reconciliation at shift changes, as narcotic count sheets from April to July 2024 lacked the required two staff signatures. Observations and staff interviews confirmed that narcotic counts were often not performed by two licensed staff members, as required. Facility leadership was unaware of these lapses, which represent a significant deficiency in pharmaceutical services.
Facility staff failed to perform proper hand hygiene during incontinence care for three residents, leading to a deficiency in infection prevention. Staff were observed changing gloves without washing hands, and the facility's handwashing policy lacked guidance on alcohol-based sanitizers. Interviews revealed inconsistencies in the availability of hand sanitizers, complicating adherence to hygiene protocols.
The facility failed to conduct regular inspections of bed rails, leading to potential safety risks for four residents. Despite policy requirements, entrapment assessments were not completed, and observations showed residents with bed rails up without proper documentation. Staff interviews revealed confusion about responsibility for entrapment measurements, posing a risk of harm.
The facility failed to properly contain waste, as the outdoor dumpster was uncovered and lacked lids, with waste scattered around it. This led to two cats rummaging through the waste. The administrator and Dietary Manager were unaware of the lack of a lid and there was no written policy for waste disposal.
A housekeeper in an LTC facility misappropriated funds by stealing a resident's wallet and using the debit card without consent. The resident, who was cognitively intact, reported the missing wallet and unauthorized charges. An investigation confirmed the housekeeper's actions through surveillance footage and interviews, revealing a failure in protecting the resident's belongings.
The facility failed to maintain an operational call light system as staff did not consistently use wireless nurse call pagers, affecting 56 residents. Call lights were often unanswered for extended periods, with staff relying on central computer stations and ticker screens instead of pagers. The DON and administrator acknowledged the issue, emphasizing the need for prompt response to call lights.
The facility failed to update care plans for four residents after falls, despite policy requirements for ongoing assessment and updates. The DON acknowledged responsibility, but care plans lacked new interventions. Communication issues, such as CNAs not having access to event reports and reliance on verbal updates, contributed to the deficiency.
A resident with cognitive impairment and hemiplegia did not receive timely toileting assistance and incontinence care, resulting in the resident remaining wet and unclean. The care plan lacked specific instructions on toileting frequency, and a CNA failed to perform necessary perineal care. Interviews with staff highlighted the importance of regular toileting to prevent skin breakdown and infection.
A CNA failed to secure the safety strap during a mechanical lift transfer for a cognitively impaired resident with hemiplegia, leading to a deficiency in accident prevention. The resident's right arm was not holding onto the lift, and the shin strap was missing. The DON and administrator were unaware of the missing shin strap, despite recent staff training on transfers.
Failure to document wound staging and medication administration
Penalty
Summary
The facility failed to document the stage of a pressure ulcer for one resident with a coccyx wound. The resident’s annual MDS dated 02/06/26 showed cognitive impairment and one or more unhealed pressure ulcers. The care plan dated 01/22/26 identified enhanced barrier precautions related to a nephrostomy tube, feeding tube, and wound, and noted the resident was at risk for pressure ulcer due to nutrition, moisture, and bedfast/mobility status. The physician order sheet for February 2026 directed cleansing the open coccyx area, applying skin prep and Santyl, and covering with calcium alginate every night and as needed. The resident was readmitted from an acute care setting on 01/20/26 with a small pea-sized area above the coccyx. Wound assessments documented a sacral wound measuring 0.7 cm x 0.3 cm x 0.1 cm on 01/20/26 without a stage, no measurements or stage on 01/27/26, and a larger wound measuring 3.5 cm x 2.5 cm x 0.2 cm on 02/03/26 without a stage. The wound was not documented as unstageable until 02/06/26, when the measurement was 3.6 cm x 3.0 cm. During interviews, the LPN said nursing staff were responsible for measuring wounds and the DON was responsible for staging them, and both the LPN and DON acknowledged the wound was not staged from 01/20/26 to 02/06/26. The facility also failed to document administration of Vancomycin for another resident. The resident’s MDS showed cognitive impairment and isolation/quarantine for active infectious disease, and the care plan dated 01/19/26 identified antibiotic treatment for C. diff. The physician order sheet for January 2026 ordered Vancomycin 125 mg four times daily, but the MAR did not document administration on 01/09/26 through 01/11/26, 01/15/26, 01/19/26, 01/20/26, and 01/22/26. Nursing notes did not show staff notified the nurse or doctor that the medication was not administered. During interviews, the CMT said he/she marked the medication as not available even when it was in the cart, the LPN said staff would assume the medication was not in the cart if it was documented as not administered, and the DON and Administrator said they were not aware the antibiotic was unavailable or not given.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. Review of the facility’s Payroll Based Journal report for FY 2025 Q4 showed no RN hours on multiple Saturdays and Sundays in July, August, and September 2025. Review of the RN staff schedules for July, August, September, October, December 2025, and January through February 2026 also showed repeated days when no RN was in the building for eight consecutive hours, including weekends across several months. During interviews, the Human Resource director stated he/she was responsible for schedules and PBJ reporting and acknowledged not realizing that 12-hour nurse shifts split across two days would not satisfy the eight-hour RN requirement. The DON stated HR and the administrator handled staffing, that the facility had issues with RN coverage, that weekends lacked coverage, and that two as-needed RNs were available. The administrator also stated she was aware of the non-coverage of RN hours and that the facility had staffing difficulties.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Facility staff failed to ensure the medication error rate remained below 5%, as surveyors identified 3 medication errors out of 35 observed opportunities, resulting in an 8.57% error rate and affecting two residents. Facility policies reviewed did not contain a definition of a medication error, although the Medication Errors and Drug Reactions policy directed staff to report all medication errors immediately to the physician, DON, and administrator. The DON stated staff are expected to follow the seven rights of medication administration and that failing to do so could result in a medication error. For one resident, an order for Cephalexin 500 mg four times daily was observed as not administered at the ordered time because the CMT documented it as unavailable and said it was not in the emergency kit, while the DON later verified one tablet was in the emergency supply kit and stated the medication should have been pulled for use. For another resident, Midodrine 5 mg daily before breakfast and Pantoprazole 40 mg three times daily were observed being administered outside the ordered time window, and the CMT stated these medications were frequently given late because the night shift did not have enough staff to complete them on time. The DON acknowledged there were medication timing issues with the night shift and stated that giving medication outside the ordered time is a medication error.
Improper Medication Cart Storage and Labeling
Penalty
Summary
Staff failed to ensure medications were stored in a safe and effective manner when three of five sampled medication carts contained improperly stored and unlabeled items. Review of the facility policy showed medications must be stored in the container in which they were received and that no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. During observation, the D medication cart on the B hall contained 19 and a half unidentified loose pills, nine unidentified loose capsules, 30 ounces of opened and undated active liquid protein, one medication cup with three unidentified pills, and one small opened and undated pudding cup. Additional observations showed the C medication cart on the B hall contained 15 and a half unidentified loose pills and one unidentified capsule, and the A medication cart on the B hall contained 22 and a half unidentified loose pills and two unidentified capsules. The DON stated the CMTs passing medications on that shift were responsible for maintaining their cart and said carts should be monitored and cleaned daily as needed, but was not aware there were so many loose pills in the carts. A CMT stated there was no schedule to clean the medication carts and that the carts had not been cleaned. The Administrator stated it was the responsibility of the CMTs to maintain medication carts and that they should be cleaned at least weekly and follow the facility's medication storage policy.
Infection Control Program, Precautions, and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Review of the facility’s IPCP materials showed there was no written IPCP policy, the IPCP Procedure Manual was undated and had not been reviewed annually, and the Antibiotic Stewardship binder did not contain infection surveillance or antibiotic tracking documentation for January through May 2025 and January through February 11, 2026. During interviews, the DON stated he/she was the facility Infection Preventionist and was responsible for maintaining the IPCP, and the Administrator stated the IPCP policies and procedures should be reviewed annually. For one resident with wounds and on Enhanced Barrier Precautions, staff did not post the required EBP sign outside the room on multiple observations. The resident’s care plan indicated signage would be on the door to notify staff of EBP, and the physician order sheet showed treatment for a left heel open area with dressing changes. Observations on several dates showed the door did not have an EBP sign or PPE outside the room. The DON stated staff should wear gowns and gloves for EBP and said a sign should have been placed on the resident’s door because the resident had a wound. For another resident with an open coccyx wound and on EBP related to a nephrostomy tube, feeding tube, and wound, staff did not wear a gown or gloves when removing the wound dressing. The resident’s care plan stated staff would wear appropriate PPE while caring for the resident according to EBP, and the physician order sheet showed ongoing wound treatment. The LPN acknowledged he/she should have put on a gown and gloves before touching the wound dressing and said he/she forgot to do so. The DON and Administrator both stated staff were expected to follow the EBP guidance before touching the wound dressing. The facility also failed to follow transmission-based precautions for a resident with C-diff. The resident’s records showed isolation/quarantine for active infectious disease and nursing notes documented C-diff treatment with isolation precautions and PPE use. During observation, a CNA entered the resident’s room, touched the bedrail and call light, left the room, and then entered other residents’ rooms without applying PPE or performing hand hygiene after contact with the resident. During another observation, the DON entered the resident’s room during medication pass, administered medications and took blood pressure, then placed the blood pressure cuff on the medication cart and moved to another resident’s room without PPE, hand hygiene, or disinfecting the equipment. The DON later stated he/she did not apply the gown and gloves, did not hand wash between med passes, and did not disinfect the equipment after use. Hand hygiene was also not performed appropriately during a medication pass for five residents. The facility’s handwashing policy did not include direction on when to wash hands, although other policies stated staff should wash hands before administering medication and clean hands between resident contacts. During observation, a CMT administered medications to multiple residents and moved between residents without washing or sanitizing hands, including after handling a soiled gown and after taking a resident’s blood pressure. The CMT stated he/she was supposed to wash or sanitize hands between residents during medication pass but forgot. The DON stated staff were expected to wash or sanitize between residents during medication pass.
Failure to Maintain Antibiotic Stewardship Monitoring and Tracking
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility policy directed the Infection Preventionist (IP) or designee to audit antibiotic prescribing documentation, including dose, route, start date, end date, days of therapy, and indication, and to track C. difficile and antibiotic-resistant infections. However, staff did not have a process in place to track and trend antibiotic usage, and the facility did not have infection/antibiotic control logs for January through May 2025 or for January through February 2026. Review of the facility's infection/antibiotic control logs showed incomplete documentation for multiple antibiotics. In September 2025, 24 antibiotics were used, with missing documentation for signs and symptoms, site of infection, onset of symptoms, culture status, and pathogen identification. In October 2025, 24 antibiotics were used, with similar missing documentation. In November 2025, 12 antibiotics were used, with missing documentation for signs and symptoms, site of infection, culture status, and pathogen identification. In December 2025, seven antibiotics were used, and all seven lacked documentation of signs and symptoms, with additional missing information for site of infection, culture status, and whether the infection was resolved. During interviews, the DON stated he/she was the IP, was responsible for the program, and was unsure why it had not been completed before starting; he/she also stated the logs had not been filled out for the last two months and that no trending was being done. The administrator stated the DON was responsible for maintaining the program and was not aware that the logs and trending were not being done.
Failure to Maintain Comfortable Sound Levels Due to Broken Exit Door Keypad
Penalty
Summary
Facility staff failed to maintain a comfortable and homelike environment by not ensuring a functional keypad on the secure metal door leading to an outside exit on C hall, resulting in a loud, continuous beeping noise each time staff entered or exited. The facility lacked an environmental policy, and the keypad had been broken for at least a couple of weeks, according to staff. The beeping occurred whenever staff held down the metal bar for 15 seconds to open the door and continued until a code was entered on the other side. Multiple observations over several days showed frequent, loud beeping from this door as various staff, including maintenance, CNAs, laundry, and housekeeping personnel, repeatedly used the door throughout the day. Each observed use required holding the bar down for 15 seconds, triggering the loud alarm-like sound. This occurred many times in a short period on multiple days, demonstrating an ongoing and unresolved environmental issue affecting the sound level in the hallway. Residents reported that the noise disturbed their rest and comfort. One resident stated the beeping came from the broken back door to the laundry room, reported that staff began arriving early in the morning, and said the noise often woke them up and made them feel "crazy." Another resident said the loud beeping sounded like a fire alarm, believed the door was broken, and reported being awakened in the mornings and hearing the sound periodically all day and sometimes at night, stating it bothered everyone. Staff interviews confirmed awareness of the broken keypad and frequent use of the door, while leadership interviews showed that the DON and administrator were not aware of the problem until the surveyors arrived, and that the maintenance director was waiting on invoices to be paid before ordering the needed part.
Failure to Post Accessible State Complaint Hotline Information
Penalty
Summary
The facility failed to post the required DHSS hotline information for reporting allegations of abuse and neglect, or a list of names, addresses, and phone numbers of the State Survey Agency, in a form and manner accessible to residents and visitors. The census was 53.1. Review of the facility’s policies showed there was no policy addressing the required postings. On observation, staff had posted the Elder Abuse Hotline number and contact information, but it was not accessible to all residents and resident representatives. During interviews, Resident #44 said he/she was not aware of the number being posted in the building but found it, and Resident #1 said he/she was not aware of the hotline number or its posted location. CNA E, CNA F, and LPN A each stated they were not aware of the hotline number or where it was posted. The DON said the hotline number was in the hall by the main entry and acknowledged it might be too high and the font size might be too small for residents to use discreetly. The administrator said the sign was in the hall of the front office, but was not sure it was visible from its location and thought it should be lowered and the font made larger.
Dialysis Care Orders and Clinic Contract Missing
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who received dialysis at an outside clinic. The resident had intact cognition, a diagnosis of ESRD, and received dialysis on Monday, Wednesday, and Friday. The resident's record did not contain a contract between the facility and the dialysis clinic, and the physician order sheet for February 2026 did not include an order for dialysis or an order to check the resident's AV graft. The MAR also did not include direction for staff to check the AV graft. During interview, the resident stated the AV graft was in the left arm and that the dialysis clinic covered the site with band aids after treatment, while facility staff only sometimes checked the graft. An LPN stated he/she did not know whether the facility had a contract with the dialysis clinic and said the resident should have physician orders for dialysis and for AV graft checks, but those orders were not present and may have been overlooked. The DON stated the facility believed it had a contract but did not have a copy, and also said there was no order in place directing staff to check the AV graft. The administrator stated the facility had been trying for weeks to obtain a contract from the dialysis clinic but had not received one.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility staff failed to notify the State Long-Term Care Ombudsman in writing of resident transfers to the hospital, including the reason for transfer, for four residents out of 14 sampled. The facility's policies did not include a procedure for notifying the ombudsman about transfers and discharges. The medical records of the residents involved did not contain documentation that the ombudsman was notified of their transfers to acute care or the emergency room. This lack of notification was identified for residents who were transferred on various dates and subsequently readmitted to the facility. Interviews with facility staff revealed a breakdown in the notification process. The Social Service Director (SSD) indicated that notifications to the ombudsman were dependent on receiving bed hold information from nursing staff, which was not consistently completed. The Administrator acknowledged the issue, stating that ombudsman notifications were not being completed as required. Other staff members, including an LPN, the ADON, and a Nurse Consultant, were either unaware of the notification responsibilities or the fact that notifications were not being completed. This indicates a lack of clarity and communication among staff regarding the notification process for resident transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to inform residents and/or their representatives in writing about the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for four residents out of a sample of 14, with the facility's census being 54. The facility's Bed Hold Policy Guidelines require notification upon admission, at the time of transfer, and during non-covered therapeutic leave. However, reviews of the medical records for the affected residents showed no documentation of such notifications being provided prior to their transfers. Interviews with facility staff, including the Social Service Director, the administrator, LPNs, the ADON, and the Nurse Consultant, revealed a lack of clarity and accountability regarding the completion and monitoring of bed hold forms. The charge nurses were identified as responsible for completing these forms, but there was a breakdown in the process, as evidenced by the absence of completed forms. The administrator acknowledged awareness of the issue, while the ADON and Nurse Consultant were unaware that the bed holds were not being completed. This lack of communication and oversight contributed to the deficiency in notifying residents and their representatives about the bed hold policy.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility staff failed to develop and implement comprehensive person-centered care plans for seven residents out of a sample of 14, despite having a policy in place to use the CMS Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual as a guide. For Resident #16, the care plan inaccurately documented hospice services even after the resident was discharged from hospice, and there was no corresponding physician order for hospice care. Resident #21's care plan lacked directions for anticoagulant medication and nectar thickened liquids, despite the resident being on Xarelto and requiring a mechanical soft diet. Resident #25's care plan contained conflicting code status information, listing both full code and Do Not Resuscitate (DNR) status, and failed to include directions for toileting, hygiene, dressing, or the use of a right arm tray on the wheelchair, despite the resident's observed needs. Resident #32's care plan did not include a plan for hospice care, even though the resident had a signed contract and consent for hospice services. Resident #33's care plan did not address the use of bed rails, which were observed in use, and there were no corresponding physician orders for bed rail use. Resident #49's care plan was missing directions for code status and bed rail use, despite observations of the resident using bed rails and having a full code status order. Resident #50's care plan did not address the resident's smoking habits, even though the resident was documented as a smoker and confirmed this during an interview. Interviews with facility staff, including CNAs, LPNs, the ADON, and the Administrator, revealed that care plans were not updated as required, and there was a lack of alignment between care plans and physician orders, leading to deficiencies in resident care planning.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility staff failed to provide activities of daily living (ADLs), specifically showers, for eight residents out of fourteen sampled. These residents were not consistently listed on the master shower schedule, leading to missed showers. The facility's policy required residents to be on the shower schedule twice a week, but this was not adhered to, resulting in some residents not receiving showers as needed. Resident #9, who was severely cognitively impaired and dependent on staff for hygiene and bathing, was not on the master shower list. Similarly, Resident #21, who required maximum assistance for transfers, toileting, and dressing, was listed to receive showers twice a week, but there was no documentation to confirm these showers were provided. Resident #23, who was cognitively intact but required assistance for bathing, reported not receiving showers twice a week as scheduled, leading to discomfort. The facility's failure to maintain an updated and accurate master shower schedule contributed to the deficiency. Interviews with staff, including the Certified Medication Technician (CMT), Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN), Assistant Director of Nursing (ADON), and the administrator, revealed a lack of clarity and responsibility in updating the shower schedule. This oversight resulted in residents, including those receiving hospice care, not being offered showers as required, highlighting a systemic issue in the facility's management of resident care.
Failure to Conduct Bed Rail Assessments and Obtain Consent
Penalty
Summary
The facility failed to complete necessary bed rail assessments and obtain informed consent for the use of bed rails for three residents out of a sample of 14, despite having a policy in place that requires these actions. The policy mandates staff to conduct bed rail observations, obtain consent, educate residents or their representatives on the risks and benefits, and develop a care plan for bed rail use. However, for Residents #21, #33, and #49, these steps were not followed, as evidenced by the lack of documented assessments and consents in their medical records. Resident #21 was assessed as requiring maximum assistance for various activities and had physician orders for bed rails, yet the medical record showed only one bed rail assessment and consent, with no further documentation. Observations confirmed the consistent use of bed rails without updated assessments or consents. Similarly, Resident #33, who was cognitively intact and required supervision for some activities, had no documented bed rail assessment or consent, despite observations showing the use of bed rails. Resident #49, with severe cognitive impairment, also lacked documentation for bed rail assessments and consents, although bed rails were observed in use. Interviews with facility staff revealed confusion and inconsistency regarding responsibilities for bed rail assessments and consent. LPN C, the maintenance person, the Nurse Consultant, and the Administrator provided conflicting information about who was responsible for these tasks and how often they should be completed. The maintenance person admitted to not performing entrapment measurements, and there was uncertainty about who should conduct these measurements. This lack of clarity and adherence to policy contributed to the deficiency in ensuring resident safety regarding bed rail use.
Failure to Ensure Timely Completion of Nurse Aide Training
Penalty
Summary
The facility failed to ensure that four nurse aides completed the required nurse aide training program within four months of their employment. The facility's policy did not provide guidelines for the completion of the nurse aide training program, and the Facility Assessment Tool indicated that all nurse aides must be certified within 120 days. Personnel files for the nurse aides in question lacked documentation of completed training, and observations revealed that one of the nurse aides did not perform proper hand hygiene during care procedures. Interviews with various staff members, including the Business Office Manager, Administrator, Director of Nursing, ALF Coordinator, Assistant Director of Nursing, and Nurse Consultant, revealed a lack of clarity and communication regarding the responsibility for monitoring the completion of the CNA training. The ALF Coordinator was identified as responsible for tracking CNA class completion, but there was a breakdown in communication and follow-up, resulting in the nurse aides being out of compliance and continuing to work without completing their training. The facility staff were aware of the issue but did not take effective action to address it, leading to the deficiency.
Failure to Reconcile Narcotics at Shift Change
Penalty
Summary
The facility staff failed to adhere to their policy regarding the reconciliation of narcotics at the change of shift. The policy required that narcotics be counted and verified by two licensed staff members at each shift change, with both individuals signing the narcotic count log to confirm the accuracy of the count. However, a review of the narcotic count sheets from April to July 2024 revealed numerous instances where the sheets lacked the required two signatures, indicating that the counts were not consistently performed by two staff members as mandated. Observations and interviews with staff members further confirmed the deficiency. On one occasion, an LPN was observed beginning their shift without completing a narcotic count with the outgoing nurse. Interviews with various staff, including LPNs, CMTs, the Assistant Director of Nursing, and the Nurse Consultant, revealed a pattern of non-compliance with the narcotic counting procedure. Staff members admitted to either not performing the counts or doing so alone, contrary to the facility's policy. The facility's leadership, including the Administrator and the Director of Nursing, were unaware of the lapses in narcotic counting procedures. They expressed expectations that the counts be completed by two licensed staff members at each shift change and that both sign the narcotic log. The failure to consistently follow the established procedure for narcotic reconciliation at shift changes represents a significant deficiency in the facility's pharmaceutical services.
Deficiency in Hand Hygiene Practices
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols, leading to a deficiency in infection prevention and control. Observations revealed that staff members did not perform hand hygiene after glove removal and before donning new gloves during incontinence care for three residents. For Resident #14, staff members were observed changing gloves without washing hands after providing bowel incontinence care. Similarly, for Resident #24, a CNA applied barrier cream with soiled gloves and changed gloves without hand hygiene. For Resident #35, a CNA changed gloves multiple times during catheter and incontinence care without performing hand hygiene. The facility's handwashing policy did not address the use of alcohol-based hand sanitizers or provide specific guidance on when to wash hands. Interviews with staff indicated a lack of available hand sanitizers in resident rooms, complicating adherence to proper hand hygiene practices. The Director of Nursing acknowledged the expectation for staff to perform hand hygiene during care transitions and noted that pocket-sized hand sanitizers were available, although the Administrator contradicted this by stating they were not available to staff.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed rails as part of their maintenance program, leading to potential safety risks for four residents. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment, but this was not adhered to. The FDA guidelines highlight the risks associated with bed rails, including entrapment, strangulation, and other injuries, particularly for vulnerable populations such as the elderly. Resident #21 was assessed as requiring maximum assistance for various activities and had an order for bed rails for positioning. However, there was no entrapment assessment or measurements in the resident's medical record, and observations showed the resident consistently had both half bed rails up. Similarly, Resident #25 had moderate cognitive impairment and required assistance for mobility and other activities. The bed rail assessment for this resident showed measurements that did not pass the entrapment criteria, yet staff documented them as passed. Residents #33 and #49 also had discrepancies in their care plans and medical records regarding bed rail use and entrapment assessments. Observations showed both residents with half bed rails up, but their records lacked necessary entrapment measurements. Interviews with staff revealed confusion and lack of clarity about who was responsible for conducting entrapment measurements, with different staff members providing conflicting information. This lack of coordination and adherence to safety protocols posed a risk of harm to the residents.
Improper Waste Containment
Penalty
Summary
The facility staff failed to properly contain waste and refuse, leading to the potential harboring and feeding of rodents and pests. Observations on two consecutive days revealed that the outdoor dumpster, which contained waste, was uncovered and lacked lids or doors. Additionally, paper and food waste were scattered on the ground around the dumpster, and a plastic bag of waste was found on the ground near the dumpster. On the second day, two cats were observed rummaging through the plastic bag of waste. Interviews with the facility administrator and the Dietary Manager revealed that there was no written policy for waste disposal or maintenance of waste disposal areas, and both were unaware that the dumpster did not have a lid.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
Facility staff failed to prevent the misappropriation of funds for a resident when a housekeeper stole the resident's wallet and used the debit card without consent. The facility's policy mandates protection of residents from abuse, neglect, exploitation, and misappropriation of property. Despite this, the housekeeper accessed the resident's room, took the wallet, and used the debit card for unauthorized transactions totaling $308.96. The resident, who was cognitively intact, noticed the wallet missing and reported unfamiliar charges to the bank. The facility conducted an investigation and involved the Department of Health and Senior Services and the local police. The police confirmed the housekeeper's unauthorized use of the debit card through surveillance footage and interviews. The housekeeper admitted to taking the wallet and using the card without permission. The incident highlights a failure in safeguarding the resident's belongings, as the housekeeper had access to the resident's room and exploited this access for personal gain.
Failure to Ensure Operational Call Light System
Penalty
Summary
The facility staff failed to ensure the wireless call light system was fully operational at all times, as direct care staff did not consistently carry and utilize the wireless nurse call pagers. This deficiency had the potential to affect all 56 residents in the facility. The facility's policy on call light answering did not provide clear instructions on the use of pagers, and an approved exemption required staff to carry and use the pagers at all times to ensure resident care was not adversely affected. The call light report from a specific period showed numerous instances where call lights were not answered promptly, with delays ranging from 31 to 166 minutes. Observations revealed that the facility relied on a central call light computer station and scrolling ticker screens at the end of hallways to alert staff, rather than individual pagers. Interviews with staff members, including CNAs and a CMT, indicated that pagers were often not worn due to being lost or taken home, and staff relied on the ticker screens and computer stations to monitor call lights. The Director of Nursing and the administrator acknowledged the issue, noting that staff should wear pagers to be alerted immediately when a call light is activated. They stated that call lights should be answered within 15 minutes, with a maximum acceptable delay of 30 minutes. However, the report documented that call lights were frequently left unanswered for much longer periods, which could potentially result in harm to residents.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility staff failed to revise comprehensive person-centered care plans for four residents who experienced falls. The facility's policy requires ongoing assessment and updating of care plans when significant changes occur in a resident's condition. However, the care plans for these residents did not include new interventions or reviews following their falls, despite the Director of Nursing (DON) acknowledging responsibility for ensuring updates after such incidents. Resident #2, who is cognitively impaired and has a history of falls, was found on the bathroom floor, but the care plan was not updated with new interventions. Similarly, Resident #13, who is cognitively intact with a seizure disorder and traumatic brain dysfunction, experienced two falls, yet the care plan lacked new interventions. Resident #14, also cognitively intact, fell while attempting to get into bed without assistance, but the care plan did not reflect any new interventions. Resident #18, with schizophrenia, fell from bed, but the care plan was not updated despite an increase in antipsychotic medication. The facility's process for communicating care plan updates to staff was inadequate. CNAs do not have access to event reports, and the DON relies on nurses to verbally communicate changes. The MDS nurse is responsible for ensuring care plan updates, but the lack of access to event investigations for floor staff and reliance on verbal communication led to deficiencies in care plan updates after falls.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely toileting assistance and incontinence care for a resident, leading to the resident remaining unclean and wet. The resident, who was cognitively impaired and had functional impairment on one side due to hemiplegia, required substantial assistance for toileting and was frequently incontinent of bladder and occasionally incontinent of bowel. The care plan did not specify how often to offer toileting or provide incontinence care. During an observation, a CNA transferred the resident to the toilet and found the resident's clothing and wheelchair pad saturated with urine. The CNA did not perform perineal care, leaving the resident with a smell of urine. Interviews with facility staff, including the CNA, DON, and administrator, revealed that residents should be toileted every two to three hours to prevent skin breakdown and infection. The CNA admitted to being in a hurry and not performing the necessary perineal care, while the DON and administrator emphasized the importance of regular toileting and perineal care. The facility's Perineal Care policy lacked specific instructions on the frequency of care, contributing to the deficiency.
Failure to Secure Safety Straps During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide safe transfers with a mechanical lift for a resident, leading to a deficiency in accident prevention. The facility's Hydraulic Lift policy, which was undated, required adherence to the manufacturer's instructions for safe use. The hydraulic lift manual from September 2023 specified that residents should have some weight-bearing ability, upper body strength, and the ability to follow simple commands. It also required the safety strap to be securely fastened around the resident's torso, with the resident's arms positioned outside the harness and hands on the paddle handles. Additionally, if necessary, shin straps should be used to keep the resident's feet on the footplate. During an observation, a CNA assisted a cognitively impaired resident with hemiplegia in a transfer using the lift but failed to secure the safety strap around the resident's torso. The resident's right arm was not holding onto the lift, and the shin strap was missing. The CNA acknowledged the missing shin strap and the need to secure the chest strap. Interviews with the DON and the administrator revealed that staff had received transfer training, and both were unaware of the missing shin strap. The administrator expected staff to use the lift as intended by the manufacturer to prevent falls or injuries.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 412 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pacific
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Andrew's At Francis Place | 6 mi | ★★★★★ | 2 | 0 |
| Marymount Manor | 7.3 mi | ★★★★★ | 1 | 0 |
| Aegis Health And Rehabilitation | 9.9 mi | ★★★★★ | 1 | 0 |
| Arbor View Nursing And Rehabilitation | 10.2 mi | ★★★★★ | 1 | 0 |
| Ellisville Rehabilitation And Nursing | 10.7 mi | ★★★★★ | 22 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.